Opportunistic

Fungi (systemic mycoses II)

Causative Agents

Candida albicans

Other Canidia

Aspergillus
A. fumigatus, A. flavus, A. niger, A. terreus

Pigeon feces***** (dry areas)

(pigeons are a major reservoir)
This is unlike histoplasmosis which is just lives in the soil that
has guano/ feces

Endogenous****** (normal enteric flora)

Transmission

Cryptococcus neoformans

Initiation of disease is due to problems in the host that allows invasion of

sterile sites (blood, lung, liver), or overgrowth in a place with normally
controlled amounts

Inhalation of conidia
(although other forms as well)

Rhizopus

Absidia

Mucor

Respiratory (or ear?) portal of entry (common bread molds)

Pneumocystis jiroveci

Hyalohyphomycoses

Respiratory portal of entry

Inhaled, spreads to CNS (AIDS)

Still Only Yeasts

Candidiasis
Cutaneous infection
Caused by break down of skin integrity/ loss of barrier
Burns****
Chronic moisture & maceration
-Dishwashers, bartenders, intertrigonous area of obese,
diaper rash on babies

Disease

Chronic mucocutaneous candidiasis (CMC)

Recurrent severe ulcerative lesions of mucocutaneous areas and skin
DOES NOT disseminate
Occurs in kids with genetic defects in leukocytes (T-Cells)

C. tropicalis / C. parapsilosis
Found on skin
Put in blood by IV drug use***
Endocarditis
C. glabrata & C. kruseii
Resistance to fluconazole

Cryptococcosis
Chronic subacute, acute pulmonary or systemic
Enters via inhalation, primary infection very mild

Aspergillosis
Aspergilloma
Fungus ball
Occurs in preexisting cavity in lung from tuberculosis or sarcoidosis

Serious, life threatening infections in patients with impaired CM

defenses, especially those lacking good T-cells like AIDS &
Lymphoma

Disseminated
Involves 2 or more non-continguous organ systems

Cryptococcal meningitis*****
-Cryptococcus loves the CNS

Allergic bronchopulmonary
Hypersensitivity reaction to spores, no tissue invasion

#1 fatal fungal infection in AIDS Patients

Other sites of infection

UG tract: Vaginitis (yeast infection), Urethritis, Cystitis,
Oropharynx = ORAL TRUSH, Esophagitis
Skin, Nail (discoloration)
Cardiovascular system (endocarditis)
Can escape to lungs, brain, kidneys

Zygomycosis/ mucormycosis

PCP
Subclinical infection common

Extremely ACUTE & FULMINANT

Rhinocerebral infection (most common)
Rapidly progressive infection of sinuses, orbits & brain
This causes infarction and necrosis
Associated with diabetic ketoacidosis
-Lots of sugar makes them susceptible to worst infection

Other types:
Skin infection (burn patients)
Invasive
Abdominal/ gastric infections
Parenchymal invasion with hyphal preogression along vascular pathways Thoracic infection

Yeast

Alveolar macrophages & CD4 important in host

defense
Rare extrapulmonary infection of liver or bone
marrow infection
Lung infection associated with:
Debilitation
Immunosuppression (AIDS*****)

Mycotoxicoses
Eating food contaminated w/ aflatoxins
Invasive/disseminated Asperillosis
-often fatal in immunocompromised
-RF: neutropenia, neoplasm, organ transplant, chemo, steroids

Yeast-like
3 forms:
1)Trophic form

Yeast
Produces single of double buds (blastospores)

2) Uninucleated sporocyst
No germ tubes or pseudohyphae

Virulence Factors:
-Can grow at high temps
-Ability to adhere to cell surfaces
-Produce proteases

3) Mature spore case containing 8 oval fusiform

spores

Polysaccharide capsule**** serves as virulence factor

Monomorphic Mold ALWAYS

Conidiophores (terminal vesicle)
Phialides w/ conidia chains

Mold

Septate hyphae w/ 45 branching******

Mold
rhizoids
opposite
sporangiophores

Mold
rhizoids
(internodal)
between
2 sporangiophores

Mold
NO rhizoids***

Mycelium has septate hyaline hyphae

Germ tube test (Only C. Albicans makes germ tubes*****)
Incubated 2- 4 hrs @ 37C in bovine serum
See germ tubes as primary hyphal elements w/ parallel sides & nonconstricted attachment to yeast cell
Chlamydoconidia formation (Only C. albicans has these)
See large thick-walled chlamydoconidia (on corn meal agar)
Carbohydrate fermentation
Same as bacteria, can determine species
Diagnosis

CHROMagar candida
Selective for candidia
Differential for candida species (colors)
-Detection of Candida in 'sterile' sites (especially blood)
Note: presence of Candida in mucosa/ GI is NOT diagnostic

Direct examination
-India Ink prep on CSF
--> low sensitivity
-Histopathological stains of tisse
--> GMS, PAS, mucicarmine stain (stains capsule)
Culture
**CSF**
-Blood, tissue, respiratory secretions
-Smooth, moist colonies on routine fungal media incubated at
#%C for 48-72 hrs

Direct tissue exam:

Use GMS, PAS, calcofluor stains
Look for Septate hyphae w/ 45 branching
Culture:
Growth of hyaline mold in 1-2 days on routine fungal media @ 25C
A. fumigatus has green colonies
Serology:
Ab tests for allergy & aspergilloma only
Galactomannan Ag test

ID
-Capsule via India ink
-Production of blastospores only
-Urease production
-Pigmented colonies on caffeic acid ("bird seed") agar
--> phenol oxidase production

CAN'T be Cultured
Seen in lung biopsy or lavage

Direct tissue exam

ALL 3 species have:
Broad, NON-septate hyphae w/ 90 branching******
Rapid growth*** on fungal media
Species determined by sporulation & rhizoid pattern

Methenamine silver stain (stains sporocyst

wall)
Giemsa (trophic form nuclei),
Immunoflorescent antibody stain (sensitive)

Serology
-latex agglutination test
--> detects cryptococcal polysaccharide in CSF & serum
--> more sens. vs. India Ink

Allergic Disease: Steroids

Topicals for uncomplicated cutaneous disease:

Nystatin, Miconazole, Clotrimazole
Treatment

Invasive/ Disseminated:
Amphotericin B, Liposomal AMB, Fluconazole
Voriconazole, Caspofungin

Amphotericin B 5FC
Fluconazole (life-long suppression in AIDS pts.)

Aspergilloma: surgical resection

Invasive:
Voriconazole
Amphotericin B
Caspofungin

Penicillium spp.
-Blue green colonies
-Produces conidiophores
w/secondary branches (metulae)
-Whorled phialides that bear
conidia in chains (peicillus)
Fusarium spp.
-white-to-pink colonies
-Banana-shaped conidia
-Eye, skin, nail infections
-Occasionally disseminates
Paecilomyces
-Lemon-yellow colony
-Tapered phialides & oblong
conidia
-Usually contaminant

Oval yeast w/ pseudohyphae (buds that fail to detach)

Reproduce by budding
Colonies white and creamy on Sabroud dextrose agar grows very
quickly (24-48 hrs)

Hallmark:
Interstitial pneumonitis (PCP) + plasma cell
infiltration

Opportunistic pathogens
-Rapid growing
-Hyaline monomorphic molds
-Can be overlooked as
contaminants
-Infect skin, soft tissue
but may disseminate

SMX/TMP or Dapsone
Liposomal Amphotericin B ****
Posaconazole
Surgical resection

+ Steroids (acutely ill, immunocompromised)

2nd line:
Clindamycin, petnamidine, primaquine,
atovaquone

Scopulariopsis
-white-to tan-brown colony
-Large, ovoid spiny conidia w/
truncated base (lightbulb shape)
-Rare nail infections
Acremonium spp.
-White cottony colony
-Delicate taping conidiophores w/
oblong conidia occuring in clumps
@ terminal ends
-Corneal and nail infections
Rare cause of mycetoma
(maduras foot)

Notes

Predisposing factors:
Steroids/ Chemo, Antibiotics, Percutaneous catheters,
Metabolic abnormalities (diabetes/ hypothyroidism)
Cancer, IV drug use
Antibody test are not helpful since most people have Candida
endogenously

-White, cottony mold, rapid growth (1-2 days) @ 25C on

standard fungal media, colony turns dark upon sporulation
-Hyphae are hyaline & non-septate, asexual reproduction by
production of sporangia & sporangiospores